Further Outpatient Care

Uncomplicated cases of bacterial vaginosis (BV) typically resolve after the standard antibiotic treatment.

BV that does not resolve after one course of treatment may be cured by a second course with the same agent. Another option is to switch to another agent (ie, metronidazole to clindamycin, or clindamycin to metronidazole) as other concomitant organisms may respond better to an alternate medication. Metronidazole is favored because it allows faster return of colonization of H₂ O₂ -producing lactobacilli.^[26]

Some women with recurrent episodes of BV may benefit from treatment of Gardnerella vaginalis in their sexual partner if colonization is demonstrated, although this is controversial and not usually supported by the data. A Cochrane review found that antibiotic treatment for sexual partners of women with bacterial vaginosis had no effect on the rate of improvement in the women.^[27] Repeating wet preps is useful because patients can develop new, non-BV infections such as Candida. Using other diagnostic modalities may prove helpful, such as the DNA tests that may allow for more specific delineation of bacterial species, which will allow for more specific antibiotic treatment. A temporary use of condoms with their partner may help prevent recurrent infections.

Testing for other infections, such as N gonorrhoeae, C trachomatis, and herpes simplex virus type 1 (HSV-1) may be appropriate in individuals with BV because the incidence of sexually transmitted diseases (STDs) may be increased in this population depending upon the risk factors and demographics.

Therapy with metronidazole or clindamycin may alter the vaginal flora and predispose the patient to development of vaginal candidiasis.

Discourage douching, bubble baths, and over-the-counter vulvovaginal hygiene products.

Deterrence/Prevention

Predisposing factors that may contribute to development of bacterial vaginosis (BV) are listed below. Correction or modification of the following factors may help reduce the incidence or recurrence of BV:

Recent antibiotic use
Decreased estrogen production of the host
Wearing an IUD
Douching
Bubble baths
Feminine hygiene products (sprays and other vulvovaginal products marketed for feminine cleanliness)
Liquid soaps and body washes (hypoallergenic bar soaps are superior)
Sexual activity leading to transmission, as evidenced by the patient having a new sexual partner, an increased number of sexual partners in the month preceding the onset of BV symptoms, and an increased number of lifetime sexual partners

Questions

Brocklehurst P, Gordon A, Heatley E, Milan SJ. Antibiotics for treating bacterial vaginosis in pregnancy. Cochrane Database Syst Rev. 2013 Jan 31. 1:CD000262. [QxMD MEDLINE Link].
Amsel R, Totten PA, Spiegel CA, Chen KC, Eschenbach D, Holmes KK. Nonspecific vaginitis. Diagnostic criteria and microbial and epidemiologic associations. Am J Med. 1983 Jan. 74(1):14-22. [QxMD MEDLINE Link].
Schuyler JA, Mordechai E, Adelson ME, Sobel JD, Gygax SE, Hilbert DW. Identification of intrinsically metronidazole-resistant clades of Gardnerella vaginalis. Diagn Microbiol Infect Dis. 2015 Oct 8. [QxMD MEDLINE Link].
Tabrizi SN, Fairley CK, Bradshaw CS, Garland SM. Prevalence of Gardnerella vaginalis and Atopobium vaginae in virginal women. Sex Transm Dis. 2006 Nov. 33(11):663-5. [QxMD MEDLINE Link].
Patterson JL, Girerd PH, Karjane NW, Jefferson KK. Effect of biofilm phenotype on resistance of Gardnerella vaginalis to hydrogen peroxide and lactic acid. Am J Obstet Gynecol. 2007 Aug. 197(2):170.e1-7. [QxMD MEDLINE Link]. [Full Text].
Fredricks DN, Fiedler TL, Thomas KK, Oakley BB, Marrazzo JM. Targeted PCR for detection of vaginal bacteria associated with bacterial vaginosis. J Clin Microbiol. 2007 Oct. 45(10):3270-6. [QxMD MEDLINE Link]. [Full Text].
Meriwether KV, Rogers RG, Craig E, Peterson SD, Gutman RE, Iglesia CB. The effect of hydroxyquinoline-based gel on pessary-associated bacterial vaginosis: a multicenter randomized controlled trial. Am J Obstet Gynecol. 2015 Nov. 213 (5):729.e1-9. [QxMD MEDLINE Link].
Harrison P. Bacterial Vaginosis Raises HIV Risk, Lowers Tenofovir Level. Medscape Medical News. Available at http://www.medscape.com/viewarticle/866342. July 19, 2016; Accessed: December 7, 2016.
Payne SC, Cromer PR, Stanek MK, Palmer AA. Evidence of African-American women's frustrations with chronic recurrent bacterial vaginosis. J Am Acad Nurse Pract. 2010 Feb. 22(2):101-8. [QxMD MEDLINE Link].
Marrazzo JM, Fiedler TL, Srinivasan S, et al. Extravaginal reservoirs of vaginal bacteria as risk factors for incident bacterial vaginosis. J Infect Dis. 2012 May 15. 205(10):1580-8. [QxMD MEDLINE Link]. [Full Text].
Coughlin G, Secor M. Bacterial vaginosis: update on evidence-based care. Adv Nurse Pract. 2010 Jan. 18(1):41-4, 53. [QxMD MEDLINE Link].
Alcaide ML, Chisembele M, Malupande E, Arheart K, Fischl M, Jones DL. A cross-sectional study of bacterial vaginosis, intravaginal practices and HIV genital shedding; implications for HIV transmission and women's health. BMJ Open. 2015 Nov 9. 5 (11):e009036. [QxMD MEDLINE Link].
Thurman AR, Kimble T, Herold B, et al. Bacterial Vaginosis and Subclinical Markers of Genital Tract Inflammation and Mucosal Immunity. AIDS Res Hum Retroviruses. 2015 Nov. 31 (11):1139-52. [QxMD MEDLINE Link].
Schwiertz A, Taras D, Rusch K, Rusch V. Throwing the dice for the diagnosis of vaginal complaints?. Ann Clin Microbiol Antimicrob. 2006 Feb 17. 5:4. [QxMD MEDLINE Link]. [Full Text].
Mohanty S, Sood S, Kapil A, Mittal S. Interobserver variation in the interpretation of Nugent scoring method for diagnosis of bacterial vaginosis. Indian J Med Res. 2010 Jan. 131:88-91. [QxMD MEDLINE Link].
West B, Morison L, Schim van der Loeff M, et al. Evaluation of a new rapid diagnostic kit (FemExam) for bacterial vaginosis in patients with vaginal discharge syndrome in The Gambia. Sex Transm Dis. 2003 Jun. 30(6):483-9. [QxMD MEDLINE Link].
Reid G, Burton J, Hammond JA, Bruce AW. Nucleic acid-based diagnosis of bacterial vaginosis and improved management using probiotic lactobacilli. J Med Food. 2004 Summer. 7(2):223-8. [QxMD MEDLINE Link].
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Author

Philippe H Girerd, MD Associate Professor, Department of Obstetrics and Gynecology, Virginia Commonwealth University, Medical College of Virginia

Philippe H Girerd, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Medical Society of Virginia, AAGL

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

A David Barnes, MD, MPH, PhD, FACOG Consulting Staff, Department of Obstetrics and Gynecology, Mammoth Hospital (Mammoth Lakes, CA), Pioneer Valley Hospital (Salt Lake City, UT), Warren General Hospital (Warren, PA), and Mountain West Hospital (Tooele, UT)

A David Barnes, MD, MPH, PhD, FACOG is a member of the following medical societies: American College of Forensic Examiners Institute, American College of Obstetricians and Gynecologists, The Society of Federal Health Professionals (AMSUS), American Medical Association, Utah Medical Association

Disclosure: Nothing to disclose.

Chief Editor

Michel E Rivlin, MD Former Professor, Department of Obstetrics and Gynecology, University of Mississippi School of Medicine

Michel E Rivlin, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, Mississippi State Medical Association, Royal College of Surgeons of Edinburgh, Royal College of Obstetricians and Gynaecologists

Disclosure: Nothing to disclose.

Additional Contributors

Thomas Michael Price, MD Professor Emeritus, Department of Obstetrics and Gynecology, Division of Reproductive Endocrinology and Infertility, Former Director of Reproductive Endocrinology and Infertility Fellowship Program, Duke University Medical Center

Thomas Michael Price, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Obstetricians and Gynecologists, American Society for Reproductive Medicine, Phi Beta Kappa, Society for Reproductive Endocrinology and Infertility, Society for Reproductive Investigation

Disclosure: Received research grant from: Insigtec Inc<br/>Received consulting fee from Clinical Advisors Group for consulting; Received consulting fee from MEDA Corp Consulting for consulting; Received consulting fee from Gerson Lehrman Group Advisor for consulting; Received honoraria from ABOG for board membership.

Acknowledgements

Burke A Cunha, MD Professor of Medicine, State University of New York School of Medicine at Stony Brook; Chief, Infectious Disease Division, Winthrop-University Hospital

Burke A Cunha, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and Infectious Diseases Society of America

Disclosure: Nothing to disclose.

Diana Curran, MD, FACOG Assistant Professor, Residency Program Director, Department of Obstetrics and Gynecology, University of Michigan Health Systems

Diana Curran, MD, FACOG is a member of the following medical societies: American College of Obstetricians and Gynecologists, American Medical Association, and Central Association of Obstetricians and Gynecologists

Disclosure: Nothing to disclose.

Eric A Hansen, DO, Fellow, Clinical Instructor, Department of Internal Medicine, Division of Infectious Diseases, Winthrop-University Hospital, State University of New York at Stony Brook

Disclosure: Nothing to disclose.

Clinical Elements		Bacterial Vaginosis	Trichomoniasis	Vaginal Candidiasis
Symptoms	Vaginal odor	+	+/-	-
	Vaginal discharge	Thin, gray, homogenous	Green-yellow	White, curdlike
	Vulvar irritation	+/-	+	+
	Dyspareunia	-	+	-
Signs	Vulvar erythema	-	+/-	+/-
	Bubbles in vaginal fluid	+	+/-	-
	Strawberry cervix	-	+/-	-
Microscopy	Saline wet mount
	Clue cells	+	-	-
	Motile protozoa	-	+	-
	KOH test
	Pseudohyphae	-	-	+
	Whiff test	+	+/-	-
	pH	>4.5	>4.5	< 4.5

Bacterial Vaginosis Follow-up

Further Outpatient Care

Deterrence/Prevention

References

Tables

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